SPIROMETRY

Performance and Interpretation

for
Healthcare Professionals

Faculty of Respiratory Physiology IICMS

Version 1 – April 2015

Authors: Maria Mc Neill & Geraldine Nolan

www.iars.ie
Contents Page

Background 3
What is Spirometry? 3
Definitions 3
Who should get a Spirometry test? 4
Who performs Spirometry? 4
Quality Spirometry 5
Equipment performance criteria 5
Quality Control including calibration & verification 6
Measurement procedure 7
Summary of within and between acceptability criteria for test 10
Spirometry graphs and tracings 11
Reversibility testing 13
Interpretation 14
Differential diagnosis of COPD vs Asthma 15
Guide to interpreting the results 16
Diagnostic flow chart 18
References 19

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Background
Faculty of Respiratory Physiology of Irish Institute of Clinical Measurement
Science, with the endorsement of the Irish Thoracic Society (ITS), perform
spirometry to the ATS/ERS task force (2005 update): Standardisation of
Spirometry, guidelines1.
This document is based on these guidelines and will supersede the previous ITS
document on Spirometry performance and interpretation2.

What is Spirometry?

Spirometry is a physiological test that measures how an individual inhales or

exhales volumes of air as a function of time. The primary signal measured in
spirometry may be volume or flow.

Spirometry is invaluable as a screening test of general respiratory health in the

same way that blood pressure provides important information about general
cardiovascular health. However, on its own, spirometry does not lead clinicians
directly to an aetiological diagnosis.

Spirometry can be undertaken with many different types of equipment, and

requires cooperation between the subject and the examiner, and the results
obtained will depend on technical as well as personal factors. If the variability of
the results can be diminished and the measurement accuracy can be improved,
the range of normal values for populations can be narrowed and abnormalities
more easily detected3.

Definitions
FVC (Forced vital capacity) is the maximal volume of air exhaled with maximally
forced effort from a maximal inspiration, i.e. vital capacity performed with a
maximally forced expiratory effort, expressed in litres at body temperature and
ambient pressure saturated with water vapour (BTPS).

FEV1 (Forced Expired Volume in one second): volume expired in the first second
of maximal expiration after a maximal inspiration.

FEV1/FVC: FEV1 expressed as a percentage of the FVC, gives a clinically useful

index of airflow limitation.

The ratio FEV1/FVC is between 70% and 80% in normal adults; a value less than
70% suggests airflow limitation.

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Who should get a Spirometry test?
Table 1. Indications for Spirometry

Diagnostic
To evaluate symptoms, signs or abnormal laboratory tests
To measure the effect of disease on pulmonary function
To screen individuals at risk of having pulmonary disease
To assess pre-operative risk
To assess prognosis
To assess health status before beginning strenuous physical activity
programmes

Monitoring
To assess therapeutic intervention
To describe the course of diseases that affect lung function
To monitor people exposed to injurious agents
To monitor for adverse reactions to drugs with known pulmonary toxicity

Disability/impairment evaluations
To assess patients as part of a rehabilitation programme
To assess risks as part of an insurance evaluation
To assess individuals for legal reasons

Public health
Epidemiological surveys
Derivation of reference equations
Clinical research

Who performs Spirometry?

The majority of spirometry testing is performed by qualified Respiratory
Physiologists in the acute hospital setting.

However, with adequate training, accurate and reproducible spirometry may be

performed by General Practitioners, Respiratory Nurses, Practice Nurses,
Physiotherapists and other Healthcare Professionals. An accredited spirometry
training programme is now available. The CPD Certificate in Spirometry for
Healthcare Professionals (www.iars.ie) is provided by the Irish Association of
Respiratory Scientists (now the Faculty of Respiratory Physiology IICMS) in
conjunction with Dublin Institute of Technology, Kevin Street. It is strongly
recommended that any healthcare professional taking up spirometry testing
obtain this qualification thus confirming their competency to perform quality
spirometry on patients.

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Quality Spirometry

In order to ensure accurate and reproducible data, Spirometry must be

considered under the following headings.

 Equipment performance criteria

 Equipment Validation
 Quality Control
 Subject/patient manoeuvre
 Measurement Procedure
 Acceptability
 Repeatability
 Reference Value/Interpretation
 Clinical Assessment
 Quality Assurance
 Feedback to Clinical Measurement Scientist

Equipment Performance Criteria

While manufacturers are responsible for demonstrating the accuracy
and reliability of the spirometers they sell, it is the user who is responsible for
ensuring that the equipment’s measurements remain accurate.

The spirometer must be capable of accumulating volume for 15 seconds (longer

times are recommended) and measuring volumes of ≥8 L (BTPS) with an
accuracy of at least ±3% of reading or ±0.050 L, whichever is greater, with flows
between 0 and 14 L/s-¹.
The total resistance to airflow at 14.0 L/s-¹ must be <1.5 cmH2O.L-¹.s-¹ (0.15
kPa.L-¹.s-¹) the total resistance must be measured with any tubing, valves, pre-
filter, etc. included that may be inserted between the subject and the spirometer.

Spirometer Display

For optimal quality control, both flow–volume and volume–time displays are
useful, and test operators should visually inspect the performance of each
manoeuvre for quality assurance before proceeding with another manoeuvre.
This inspection requires tracings to meet the minimum size and resolution
requirements set forth in this standard.

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Quality control including Calibration and Verification

Calibration is the procedure for establishing the relationship between sensor-

determined values of flow or volume and the actual flow or volume. Most portable
spirometers are calibrated by the manufacturer on an annual basis. Certificates
of calibration should be obtained.

A verification check is different from calibration and is the procedure used to

validate that the device is within calibration limits, e.g. ±3% of true value. If a
device fails its calibration check, then new calibration procedure or equipment
maintenance is required. Calibration checks must be undertaken daily, or
more frequently if there is a change in temperature of ≥5 degrees or if the
equipment is constantly being moved.

The syringe used to check the volume calibration of spirometers must have an
accuracy of ±15 ml or ±0.5% of the full scale (15 ml for a 3-L syringe), and the
manufacturer must provide recommendations concerning appropriate intervals
between syringe calibration checks. Users should be aware that a syringe with
an adjustable or variable stop may be out of calibration if the stop is reset or
accidentally moved. Calibration syringes should be periodically (e.g. monthly)
leak tested at more than one volume up to their maximum; this can
be done by attempting to empty them with the outlet corked. A dropped or
damaged syringe should be considered out of calibration until it is checked.

The calibration syringe should be stored and used in such a way as to maintain
the same temperature and humidity of the testing site. This is best accomplished
by keeping the syringe in close proximity to the spirometer, but out of direct
sunlight and away from heat sources.

Attention to equipment quality control and calibration is an important part of good

spirometry practice. At a minimum, the requirements are as follows:

1. A log of calibration results is maintained

2. The documentation of repairs or other alterations which return the

equipment to acceptable operation

3. The dates of computer software and hardware updates or changes

4. If equipment is changed or relocated (e.g. industrial surveys), calibration

checks and quality-control procedures must be repeated before further
testing begins.

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Key aspects of equipment quality control are summarised in Table 2.

TABLE 2 Summary of equipment quality control

Test Minimum interval Action

Volume Daily Calibration check with a 3-L syringe

Leak Daily 3 cmH2O (0.3 kPa) constant pressure for 1 min

Volume linearity Quarterly 1-L increments with a calibrating syringe

measured over entire volume range

Flow linearity Weekly Test at least three different flow ranges

Time Quarterly Mechanical recorder check with stopwatch

Software New versions Log installation date and perform test using
‘‘known’’ subject

Measurement procedure

Pre Test preparation

Patients should be advised to avoid the following prior to testing:

Smoking within 1 hour

Consuming alcohol within 4 hours
Performing vigorous exercise within 30 minutes
Wearing tight fitting clothing
Eating a large meal within 2 hours

The decision to avoid long and short acting bronchodilators is clinical and
depends on the question being asked (see section on reversibility testing).
If the test is being performed for the first time it is best to withhold medication.

Contraindications

The updated (2005) ATS/ERS task force on Standarisation of Spirometry1 states:

 Recent myocardial infarction – patients should not be tested within 1

month

 Patients with the following are unlikely to achieve optimal or reproducible

results:

 Chest or abdominal pain of any cause

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  Oral or facial pain exacerbated by a mouthpiece
 Stress incontinence
 Dementia or confused state

Spirometry test - patient steps

There are three distinct phases to the FVC manoeuvre, as follows:

1. maximal inspiration
2. a ‘‘blast’’ of exhalation
3. continued complete exhalation to the end of test (EOT)

The trained operator should demonstrate the appropriate technique and follow
the procedure described in Table 3.

The subject holds the mouthpiece between lips and teeth.

The subject should inhale rapidly and completely from functional residual
capacity (FRC), making sure the lips are sealed around the mouthpiece and that
the tongue does not occlude it, and then the FVC manoeuvre should begin with
minimal hesitation.

Reductions in PEF and FEV1 have been shown when inspiration is slow and/or
there is a 4–6 s pause at total lung capacity (TLC) before beginning exhalation.3
It is, therefore, important that the preceding inspiration is fast and any pause at
full inspiration be minimal (i.e. only for 1–2 s).

The spirometry test assumes a full inhalation before beginning the forced
exhalation, and it is imperative that the subject takes a complete inhalation
before beginning the manoeuvre.

The subject should be prompted to ‘‘blast,’’ not just ‘‘blow,’’ the air from their
lungs, and then he/she should be encouraged to fully exhale.

Throughout the manoeuvre, enthusiastic coaching of the subject using

appropriate body language and phrases, such as ‘‘keep going’’, is required.

With appropriate coaching, children as young as 5 yrs of age are often able to
perform acceptable spirometry5. The persons involved in the pulmonary function
testing of children should be specifically trained to deal with such a situation.

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TABLE 3 Procedures for Recording Forced Vital Capacity

Perform spirometer calibration/verification, only test on patient if

calibration/verification is passed

Wash hands before greeting the patient, get patient to wash their hands with
bacterial gel

Prepare the subject

Ask about smoking history, recent illness, medication use in particular inhaled
medications, etc.
Check for contraindications
Measure weight and height without shoes
Enter patient demographics accurately, age, gender, height, weight, and race

Explain the test

Instruct and demonstrate the test to the subject, to include:

Correct posture with head slightly elevated
Inhale rapidly and completely
Position of the mouthpiece (open circuit)
Exhale with maximal force

Perform manoeuvre (closed circuit method), in seated upright position

Have subject assume the correct posture, feet on floor, legs & arms uncrossed,
comfortable clothing
Attach nose clip, place mouthpiece in mouth and close lips around the mouthpiece
Inhale completely and rapidly with a pause of <1 s at TLC (total lung capacity)
Exhale maximally (blast out) until no more air can be expelled while maintaining an
upright posture
Repeat instructions as necessary, coaching vigorously
Repeat for a minimum of three manoeuvres; no more than eight are usually required
Check test repeatability and perform more manoeuvres as necessary

Perform manoeuvre (open circuit method), in seated upright position

Have subject assume the correct posture, feet on floor, legs & arms uncrossed,
comfortable clothing
Attach nose clip
Inhale completely and rapidly with a pause of <1 s at TLC
Place mouthpiece in mouth and close lips around the mouthpiece
Exhale maximally (blast out) until no more air can be expelled while maintaining an
upright posture
Repeat instructions as necessary, coaching vigorously
Repeat for a minimum of three manoeuvres; no more than eight are usually required
Check test repeatability and perform more manoeuvres as necessary

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Summary of within and between manoeuvre acceptability criteria
for spirometry test

The acceptability criteria of a spirometry trial are a satisfactory start of test and a
satisfactory end of test, i.e. a plateau in the volume–time curve. In addition, the
person should observe that the subject understood the instructions and
performed the manoeuvre with a maximum inspiration, a good start, a smooth
continuous exhalation and maximal effort.

Within manoeuvre criteria

Individual spirograpms are “acceptable” if

1. They are free from the following:

 Cough during the first second of exhalation
 Glottis closure that influences the measurement
 Early termination or cut off
 Effort that is not maximal throughout
 Leak
 Obstructed mouthpiece (e.g. obstruction due to the tongue being placed in
front of the mouthpiece, or teeth in front of the mouthpiece)
 An extra breath being taken during the manoeuvre

2. They have a good start

 Extrapolated volume <5% of FVC or 0.15L whichever is greater

3. They show satisfactory exhalation/EOT

 Duration of ≥ 6 s (3s for children) or a plateau in the volume-time curve or
if the subject cannot or should not continue to exhale.

Between manoeuvre criteria

After three acceptable spirograms have been obtained ensure the following:
The two largest values of FVC must be within 0.150L or each other
The two largest values of FEV1 must be within 0.150 L of each other
If both of these criteria are met, the test session may be concluded.

If both of these criteria are not met continue testing until;

 both of the criteria are met, or

 a total of eight tests have been performed, or
 the patient/subject cannot or should not continue

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Spirometry Graphs and Tracings
Examination of the graphical representation of a spirometry test is invaluable for
both identifying patient errors and in aiding the interpretation of spirometric
results. Two graphs are produced in a spirometry test; a flow/volume loop and a
volume time curve. It is recommended that both types of graph are produced on
the final report. The flow volume loop is very helpful at showing the start of the
test whilst the volume time graph confirms if end of test (EOT) criteria have been
met. Figures 1 and 2 show examples of common errors found on spirometry
trials. The flow volume loop is also useful in determining the pattern of
abnormality in the patient’s lung function and it is important that the graph is
reviewed as part of the interpretation process. Figures 3 and 4 show spirometry
patterns in different types of disease

Figure 1. Volume Time examples of good and poor effort

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Figure 2. Flow Volumes Curve examples of good and poor effort

Figure 3. Airways obstruction –Flow Volume Loop patterns

Normal – no airflow obstruction Mild Airflow Obstruction

Moderate Airflow Obstruction Severe Airflow Obstruction

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Figure 4. Restrictive Disorders – Flow volume loop patterns

Normal – no restriction Moderate Restrictive Defect

Severe Restrictive Defect

Reversibility Testing
Reversibility testing can be undertaken for two reasons:

1. To determine if airflow limitation can be reversed with drug administration

2. To determine whether the patients lung function can be improved with
therapy, in addition to their regular treatment.

In the latter case the subject may take their prescribed medication prior to the
test. However, in the first case the subject should undergo baseline function
testing when not taking any drugs prior to the test.

Short-acting inhaled drugs (e.g. the ß-agonist albuterol/salbutamol or the

anticholinergic agent ipratropium bromide) should not be used within 4 hours of
testing.

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Long-acting ß -agonist bronchodilators (e.g. salmetorol or formoterol) and oral
therapy with aminophylline or slow release ß -agonist should be stopped for 12 h
prior to the test.

Reversibility test procedure

The subject has three acceptable and repeatable tests of FEV1, FVC and PEF
recorded as described previously.

According to the ATS/ERS guidelines1, after a gentle and incomplete expiration,

a dose of 100 mg of albuterol/salbutamol is inhaled in one breath to TLC from a
valved spacer device.

The breath is then held for 5–10 s before the subject exhales.

Four separate doses (total dose 400 mcg) are delivered at, 30 s intervals.

This dose ensures that the response is high on the albuterol dose–response
curve. A lower dose can be used if there is concern about any effect on the
patient’s heart rate or tremor.

Other drugs can also be used.

For the anticholinergic agent ipratropium bromide, the total dose is 160 µg (8
puffs delivered).

Three additional acceptable and repeatable spirometry trials are recorded 15 min
later for short-acting ß2-agonists and 30 min later for short-acting anticholinergic
agents.

Interpretation

Interpretation begins with a review of the flow volume graph and technical
comments on test quality. Tests that are less than optimal may still contain useful
information but interpreters should identify the problems and the direction and
magnitude of the potential errors. Omitting the quality review and relying only on
numerical results for clinical decision making is a common mistake, which is
more easily made by those who are dependent upon computer interpretations.

Reference Equations

Interpretation of spirometry is usually based on comparison of data measured in

an individual patient or subjects with reference (predicted) values based on

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healthy subjects with the same sex, age, height and weight and where relevant,
ethnic characteristics of the patient being tested.

Height and weight should be measured, without shoes, for each patient at the
time of testing; a trained operator should not rely on stated height or weight.
When height cannot be measured the height can be estimated from using arm
span6.

GOLD Guidelines7

The 2014 updated GOLD guidelines have proposed four different stages of
COPD based largely on post bronchodilator FEV1 measures (Table 4).

GOLD guidelines recommend that a diagnosis of COPD should be considered

and spirometry performed for any patient who has cough, sputum production, or
dyspnoea, and/or a history of exposure to risk factors for the disease7.

This includes all current and former smokers, and any adult with a history of
exposure to tobacco smoke, occupational dusts and chemicals, or smoke from
home cooking and heating fuels.

Table 4 Classification of Severity of Airflow Limitation in COPD

(Based on Post-Bronchodilator FEV1)

Inpatients with FEV1/FVC < 0.70:

GOLD I: Mild FEV1 ≥ 80% predicted

GOLD 2: Moderate 50% ≤ FEV1 < 80% predicted

GOLD 3: Severe 30% ≤ FEV1 < 50% predicted

GOLD 4: Very Severe FEV1 < 30% predicted

Differential diagnosis of COPD vs. Asthma

COPD
Usually onset in mid-life.
Symptoms slowly progressive.
Often history of tobacco smoking.
Dyspnoea during exercise.
Largely irreversible airflow limitation.

Asthma
Onset early in life (often childhood).

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Symptoms vary from day to day.
Symptoms at night/early morning.
Allergy, rhinitis, and/or eczema may also present.
Family history of asthma.
Largely reversible airflow limitation.

Guide to Interpreting the results7

When the diagnosis is not confirmed it is recommended to apply the ATS/ERS
2005 interpretation guidelines to the spirometry results8. The ITS diagnostic flow
chart on page 18 can also be helpful in analysing the results. The following steps
are the recommended approach to spirometry interpretation as per the
accredited spirometry programme run by the IARS/DIT group.

1. Review the technical quality comment, sub optimal results need to be

interpreted with caution

2. Inspect the flow volume graph to confirm good technique and to confirm
the presence or absence of airflow obstruction (scooping out on the
expiratory portion). Figures 1 and 2, page 11

3. Start with the FEV1/FVC ratio

4. In airflow obstruction, patients cannot exhale the air in their lungs

quickly. Therefore, the FEV1 tends to fall, while the FVC remains relatively
preserved (falling only in more severe airflow obstruction). The FEV1/FVC
ratio is reduced below 70%. If this is the case, the patient may have
asthma, COPD or another cause of airflow obstruction – proceed to
point 5

5. If the FEV1/FVC ratio is greater than 70%, this usually represents

normal pulmonary function but can occasionally represent restrictive
disease. If the absolute values of FEV1 and FVC are normal, then the test
is normal. If the FEV1 and FVC values are proportionately reduced, then
the patient may have restrictive pulmonary disease.

6. The commonest cause of apparent restrictive disease is poor technique,

where the apparent reduction in FEV1 and FVC are due to poor patient
effort rather than a true reduction in their value – this underscores the
importance of observation of patient effort during the procedure.

7. The degree of airflow obstruction allows a classification of disease severity

using the GINA9 (asthma) or GOLD7 (COPD) guidelines, and appropriate
choice of therapy or action, but only patients with these diagnoses can be
stratified using these specific guidelines.

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 8. Assess the flow-volume curve to confirm your impression of the diagnosis
(Figures 3 and 4, page 12).

9. In a patient with respiratory symptoms, airway obstruction where the FEV1

and/or FVC increases by ≥12% and 200mls following bronchodilator
therapy, is suggestive of asthma.

10. In a patient with intermittent respiratory symptoms, the lack of airway

obstruction, or the lack of a bronchodilator response do not rule out
asthma. Similarly, a bronchodilator response with normal spirometry does
not always indicate asthma.

11. Airway obstruction in an adult smoker is usually (but not always) due to
COPD.

12. After spirometry, if you remain uncertain of the diagnosis, consider referral
to a hospital pulmonary function laboratory for lung volumes and a
diffusing capacity estimation (to assess for evidence of emphysema or
interstitial lung disease) or appropriate bronchial challenge provocation
test.

Table 5 Summary of Abnormal Spirometry Results

Obstructive Restrictive Combined

FEV1/FVC% ↓↓ N or ↑ ↓

FVC N or ↓ ↓↓ ↓

FEV1 ↓↓ N or ↓ ↓

N – Normal ↑ - Increased compared to predicted value

↓ - Decreased compared to predicted value

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Figure 5. Spirometry Diagnostic Flowchart2

* Reversibility testing with ß-agonist indicates an improvement of >12% and >200ml in FEV1
and/or FVC approximately 15 mins after inhalation.
** Full PFT’s refers to the measurement of diffusing capacity DLco and Lung volumes using
dilution or plethysmography in a computerized hospital based respiratory function laboratory to
determine the severity of the defect.
*** Some subjects with chronic asthma may not respond at all to a ß-agonist. Some COPD
patients may show improvement post ß-agonist.

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References
1
ATS/ERS Taskforce: Standardization of Spirometry ERJ2005; 29: 319-338
2
Spirometry performance and interpretation: A guide for general practitioners.
(2005) Dr Patrick Manning, Dr Terry O’Connor
3
A Guide to Performing Quality Assured Diagnostic Spirometry (2013). Professor
Sue Hill, Dr Robert Winter
4
D’Angelo E, Prandi E, Milic-Emili J. Dependence of maximal flow-volume curves
on time course of preceding inspiration. J Appl Physiol 1993; 75: 1155–1159.
5
Eigen H, Bieler H, Grant D, et al. Spirometric pulmonary function in healthy pre
school children. Am J Respir Crit Care Med 2001; 163: 619–623.
6
Parker JM, Dillard TA, Phillips YY. Arm span-height relationships in patients
referred for spirometry. AM J Respir Crit Care Med 1996; 154: 533-536
7
Global Strategy for the Diagnosis, Management and Prevention of COPD.
Updated 2014
8
ATS/ERS Taskforce: Interpretative strategies for Lung Function Tests.
ERJ2005; 26: 948-968
9
Global Strategy for Asthma Management and Prevention, Global Initiative for
Asthma (GINA) 2011

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